Complete only if patient is a minor and information differs from above.

Parent's Last Name

Parent's First Name

City

Street Address

State

Zip

4. Assign of Benefits/Consent for Treatment
I do hereby assign all medical and/or surgical benefits to which I am entitled, including all goverment and private insurance plans to this office. This assignment will remain in effect until revoked by me in writing. I understand that I am responsible for all charges not paid by insurance. I authorized this office to release all information necessary to secure payment. I hereby voluntarily consent to treatment at this office and authorize such treatments, examinations, medications, anesthesia, surgical, operations and diagnostic procedure (including, but not limited to the use of lab and radiographic studies) as ordered by attending physicians.
Agreed to the conditions stated above*